24027 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification PERMITN
Building -7 Ccs, S - ' _ t �Z4027 - -
2-0
- ossa. hone: A
MIt e /EYL >SS' ;(ej CITYOFCUPERTINO-BUILDING DIVISION lAlL
APPLICATION / PERMIT
BUILDING-ELECTRICA4PLUMBINGMECHAMCAL CATEGORY CONTROL X
Lk.No:
Architect/Engineer.as .: QTr ELECTRICPERMIT FEE BUILDING PERMITINFO
�jy -
Addreaw y- B9 X .3& Z- sbmL/L ❑ ❑ ❑
PERMITISSUANCE
LICENSED CONTRACTOR'S pr DECLARATIONnsofCh
gwithSherebtioo7affinthatlamlke 3ofthe erprovlslonsof Chapter ode,an enc- APPLIANCESRESIDENIIAL JOB DESCRB'DON
It ..hSection force
ofd Welon3ofthe Buslr�easand ProfeaslonsCode,and my - - -
LI.. lain full force end c.a PANELS
Dane Ciass LIcX
Date Cordractor -
ARCHITEC17SDECLARATION 201-1000 AMPS
q�v p�u.QZ.Q.. I understand my plans$hall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
N t FJ Licensed Pm esslowl SIGNS ELECTRICAL
66a IILL��y`�I OWNER-BUILDER DECLARATION I
SPECLILCIRCUIT/MLSC
BI� ]hereby affirm that l am exempt from the Contranor's License Law for the
following reason.(Section 7031.5,Business and Professions Code:Any city or -
�4 muntywhlchmquiresapermltbmrutr Oc Mter,Impn .,demoWh,orrepair TFA'tP.MECFR OR POLE INST.
any structure prior to its Issuance,also requires the applicant for such permit to
O file a signed statement that he la licenaed pursuant to the provlalore of the POWER DEVICES
3k Contractors License Law(ChaptA9(mmmendng with Section 7000)of Divi- SWIMMING TOOL ELECTRIC
Ann of the Business and Pron.W.Code)or that he Is exempt therefromand nVALUATION
' the bash for the alleged exemption. Any violation of Section 7031.5 an
<?'
applicant for a permit subjects the applicant to a civil penalty a not nrc than OUTLETSSWITCHESFIXTURES
five hundred dollars($SM.
NI,as owner of the property,or my employees with wages as their sole NEW RESIDENTIAL ELECTR—SQFT. -STORIES TYPE CONSTRUCTION
G compensation,will do the work and the strumme I.notintended or offered for
O saI-(Sec.70K Business and Professions Code:The Contra&?.Lice.Law
$$ doe. OCC.CROUP RES.UNRS
otapply to an owner of property who builds or improves thereon,
whodoes such work himself orthmugh his own employees,provided that such '
bnprovements are out intended oroffered forsale.If,howeverthebulldingor - TOTAL: "
improvementlisoldwithle oneyearofcompletb theowner-bu0derwlll have
t?IL, urden of proving that he,did not build or Unpmve for purpose of sale.). QTy. PLUMBING PERMIT FEEpLOpDWNE APN
LJ I,as owner of the pmperty,am exclusively contracting with licensed PERMIT.ISSUANCE
mntractors to mnetmct the project(Sec 7044,Business and Professions Code:
The Contractor'.License law does not apply W an owner of property who
buALTER-DRAIN kVENT-WATER(EA)
Wilds or improves thereon,and who contracts for such pto)ecta with a
c, Mer(s)licensed pursuant to the Contractor'.Licence Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
(_f I am exempt under Sec. B k P C for this reason
Owner Date r I DRAINS FIADIt,ROO$AREA,COND, SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION R_ INX
❑I hereby affirmORK that I have a SAT] n, D consent to eel!-insure,w a FIXTORES PER TRAP SCHOOL TAX- Y_ N_
certifirrteofWorkers'CompensadonlroumnmoramAlfled mpythereof(Sec. RECEIPT X
3800,Cab C.) GAS EM
EA.SYST -]INC4 OUTLETS. PARKFEE Y_ N_
Policy _ RECEPTX
Cum any GAS-FA.SYSTEM-OVER4(EA) BUILDING DIVISION FEES
Certified copyis hereby ththehed.CertiGREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
fied mpy V filed with the city Impaction division.
CERTIFICATE OF F3(EMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200F1' Date Recei t#
(This section need not becompleted B the permit la forone hundred dollars
($1 I certless.) in WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I ll nor that employ
an person
in an tmannerhe work A,as to
become
his esubjecnrdt is timed,the —
I shall not employ any person In any manner ao u to become subject to the
WorkersCompensation Laws o(GlBorolaWATER SYS,fCM/TREATING
. Date PAID
O Z Applicant "
ZQ NOITGEmrAsubImttothe C,mif rate o(Era.fthemptia Labor
TO NEW RESIDENTIAL PLMB. SQ.FI'. Date Recei t#
F shouldou=at forthwith
then ly with
Cuch pmatlon prof peoftt labor TOTAL:
a. W Cods you=att(orthwlth comply with each provklom orthia perndt .11 be U D G
W dressed revoked. FEE
IL G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a mostroctlon lending agency for the perform-
aY LECTR[GFEE.
O nce of the work for which this permit isIssued(Sec.3097,Civ.C.)
T
O _ Lender's Name PLUMBING FEE
LL F Lender's Address QTY. MECHANICAL PERMIT FEE IrertlMECHANICAL FEE
O W tythatlhavereadthisappucatianand.tatedultheeboveinfornutlon ,
6 bmrrect.I.gree to Worplywith all cityand county ordinances and elan,laws PERMTTISSUANCE FEES PAID:
} N relating to building mnstronion,and hereby authorize representatives ofthis
f• Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. Daft ReCei t#
(We)agree to save,indemnify an d keep harmless the City of Cupertino P
V' against habliMes,judgments,mita And expenses which may In anywayaarue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against consequence City in consaence of the granting of this permit. -
W E� -At t10
AIR HANDLING UNIT I0, 0CFM) CONSTRUCTION TAX
Sig fA llcant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UMT(1`0100,000 BTU) - Date ReCel f#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Healthand Safety Cade Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: "��
Yea No
Wlllthe applicant or lure building ottvpantuse equipment ordevices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air mntamb,Sm.a.defined by the Bay Area Air
Quality Management District? BOILER-COMP OHP OR 100,IXD BTU) PAI
D
I—I
We �No Ir P9
/ have read the haza ous materlab requirementsunderChapter6.95 of BOILER-COMP(OVER 100,000 BTU)
theerstan that ia Health
buildiSalcly Code,Sections 255have 33and 25534.hatit JUL
�� ����
understand that not By
ocWpoes of to requir haves tenant,that b is my NEW RESIDENTIAL MECH. SQ.FI
responsibility Issuance
of a the ocmpant"ofthe requirement which most be met
prior to issuance ofaCertlOcaM of Occupancy.
CITY ( �I tTtl'IfV
Owner or authorized agent Date ISSUEDBY:
a TOTAL:
OFFICE COPY